Provider Demographics
NPI:1346755691
Name:WALLACE, ALENA RAE (PCA)
Entity Type:Individual
Prefix:MRS
First Name:ALENA
Middle Name:RAE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:MRS
Other - First Name:ALENA
Other - Middle Name:RAE
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:243 BLACKLOG ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT GAY
Mailing Address - State:WV
Mailing Address - Zip Code:25514
Mailing Address - Country:US
Mailing Address - Phone:304-356-4562
Mailing Address - Fax:304-558-4563
Practice Address - Street 1:243 BLACKLOG ROAD
Practice Address - Street 2:
Practice Address - City:FORT GAY
Practice Address - State:WV
Practice Address - Zip Code:25514
Practice Address - Country:US
Practice Address - Phone:304-272-9025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
3810005997OtherPROVIDER ID